Registration Form

To begin requesting samples, you will need to first fill out the registration form below (Step 1)
Once approved, you will then be able to create your account (Step 2)

First name*

Last name*

Professional Title*

Specialty *

Phone number*

NPI #*

Email*

Practice / Company name*

Website URL*

Please enter the website of your company

I will be using these samples for.....*

Samples for my patients

Samples for personal use

Samples for both patients & myself

How many patients visit your practice each week?*

How were you referred to doctorsamples.com and/or the brands?*

Do you currently recommend any brands from your office?*

Misc. Notes / Comments